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Outpatient Pulmonary Rehabilitation
2 Wijkstra PJ, van Altena R, Kraan J, et al. Quality of life in patients with chronic obstructive pulmonary disease improves after rehabilitation at home. Eur Respir J 1994; 7:269 –273 3 Cambach W, Chadwick-Straver RV, Wagenaar RC, et al. The effects of a community-based pulmonary rehabilitation programme on exercise tolerance and quality of life: a randomized controlled trial. Eur Respir J 1997; 10:104 –113 4 Strijbos JH, Postma DS, van Altena R, et al. A comparison between an outpatient hospital-based pulmonary rehabilitation program and a home-care pulmonary rehabilitation program in patients with COPD: a follow-up of 18 months. Chest 1996; 109:366 –372 5 Hernandez MT, Rubio TM, Ruiz FO, et al. Results of a home-based training program for patients with COPD. Chest 2000; 118:106 –114
Several investigators have studied the role of the d-dimer test in the workup of pulmonary embolism. We are glad that the authors referred to d-dimer in their discussion. Dabbagh et al2 studied the correlation between spiral CT of the chest and d-dimer latex agglutination test (Accuclot; Sigma Diagnostics; St. Louis, MO) among 79 patients (77% women). They found that a negative d-dimer result (⬍ 0.25 g/mL) highly predicted a negative spiral CT of the chest result (negative predictive value, 100%). We believe that spiral CT scan of the chest might not be necessary in the presence of a negative d-dimer test result by latex agglutination. Although we believe that spiral CT of the chest can be very helpful in the evaluation of pulmonary embolism, we do not think it is the complete and final answer.
To the Editor: I agree that two of the studies cited in our paper as outpatientbased were, in fact, not supervised by hospital staff but were entirely community-based.1,2 I am entirely in agreement that rehabilitation programs can be very effective in the community, and indeed, while the professional input remains similar to before, our current pulmonary rehabilitation program is conducted entirely in the community, in co-operation with general practitioners. James P Finnerty, MD Countess of Chester Hospital, Chester, United Kingdom Correspondence to: James P. Finnerty, MD, Department of Medicine, Countess of Chester Hospital, Liverpool Rd, Chester CH2 1UL, United Kingdom
References 1 Wijkstra PJ, van Altena R, Kraan J, et al. Quality of life in patients with chronic obstructive pulmonary disease improves after rehabilitation at home. Eur Respir J 1994; 7:269 –273 2 Cambach W, Chadwick-Straver RV, Wagenaar RC, et al. The effects of a community-based pulmonary rehabilitation programme on exercise tolerance and quality of life: a randomized controlled trial. Eur Respir J 1997; 10:104 –113
Ousama Dabbagh, MD Carl Kaplan, MD, FCCP University of Missouri-Columbia Columbia, MO Correspondence to: Ousama Dabbagh, MD, Chief Fellow, Division of Pulmonary, Critical Care Medicine, University of MissouriColumbia, One Hospital Dr, MA417, Columbia, MO 65212; e-mail: [email protected]
References 1 Paterson I, Schwartzman K. Strategies incorporating spiral CT for the diagnosis of acute pulmonary embolism: a costeffectiveness analysis. Chest 2001; 119:1791–1800 2 Dabbagh O, Alsaleem AS, Alyaseen S, et al. The Spiral CT and D-dimer Correlation for the Diagnosis of Pulmonary Embolism Study [abstract]. Chest 2001; 120:S200
Salmeterol Powder Provides Significantly Better Benefit Than Montelukast in Asthmatic Patients Receiving Concomitant Inhaled Corticosteroid Therapy To the Editor:
Spiral CT Is Not the Final Answer To the Editor: We enjoyed reading the article by Paterson and Schwartzman in CHEST (June 2001),1 concluding that “spiral CT can replace ˙ pulmonary angiography in patients with nondiagnostic V˙/Q [ventilation/perfusion] scans.” We wish to raise several issues regarding these recommendations. This conclusion is based solely on a hypothetical model that does not represent actual clinical practice and decision making. We think that adopting their diagnostic approach may not be sufficient to exclude clinically significant pulmonary embolism. Furthermore, this could potentially lead to unnecessary treatment or lack of appropriate anticoagulation. First, there are known issues surrounding subsegmental pulmonary emboli. It is known that the sensitivity of spiral CT in this area is not high. Relying on spiral CT in these situations may result in missing small peripheral clots and their potential impact on patients with limited cardiopulmonary reserve. Second, the differences among radiologists in interpreting helical CT, especially in centers with less experience, are considerable. This fact was not discussed in this article or taken into account in their model. www.chestjournal.org
I have read with interest the study by Fish et al (August 2001).1 In this study, salmeterol added to inhaled corticosteroids was statistically superior to adding montelukast to inhaled corticosteroids in improving a number of traditional outcome variables such as morning and evening peak expiratory flow (PEF), percent of symptom-free days, percent of rescue-free days, supplemental albuterol use, nighttime awakenings, and some subjective symptoms. Reported daytime wheezing was not different. I am afraid that the design of this study favored this outcome as one of the inclusion criteria was an improvement in FEV1 of at least 12% to 2-agonists. Therefore, the observed results are not surprising, because an improvement of ⬎12% in FEV1 after treatment with 2-agonist was predetermined by these entry criteria. On the contrary, it is noteworthy that montelukast also improved the primary efficacy measure, which was PEF. While the authors claim that the sample size per treatment arm provided ⬎80% power to detect a significant difference of 15 L/min from baseline in the morning PEF, the mean difference between the two treatments observed was only 13.3 L/min. I question the scientific interpretation as well as the clinical significance of their observation. Furthermore, in my view, statistically significant differences such as a reduction of ⫺0.1 nighttime awakenings per week are hardly clinically relevant. Again, I question whether, indeed, salmeterol powder provides better benefit than monteCHEST / 121 / 6 / JUNE, 2002
2083
Several investigators have studied the role of the d-dimer test in the workup of pulmonary embolism. We are glad that the authors referred to d-dimer in their discussion. Dabbagh et al2 studied the correlation between spiral CT of the chest and d-dimer latex agglutination test (Accuclot; Sigma Diagnostics; St. Louis, MO) among 79 patients (77% women). They found that a negative d-dimer result (⬍ 0.25 g/mL) highly predicted a negative spiral CT of the chest result (negative predictive value, 100%). We believe that spiral CT scan of the chest might not be necessary in the presence of a negative d-dimer test result by latex agglutination. Although we believe that spiral CT of the chest can be very helpful in the evaluation of pulmonary embolism, we do not think it is the complete and final answer.
To the Editor: I agree that two of the studies cited in our paper as outpatientbased were, in fact, not supervised by hospital staff but were entirely community-based.1,2 I am entirely in agreement that rehabilitation programs can be very effective in the community, and indeed, while the professional input remains similar to before, our current pulmonary rehabilitation program is conducted entirely in the community, in co-operation with general practitioners. James P Finnerty, MD Countess of Chester Hospital, Chester, United Kingdom Correspondence to: James P. Finnerty, MD, Department of Medicine, Countess of Chester Hospital, Liverpool Rd, Chester CH2 1UL, United Kingdom
References 1 Wijkstra PJ, van Altena R, Kraan J, et al. Quality of life in patients with chronic obstructive pulmonary disease improves after rehabilitation at home. Eur Respir J 1994; 7:269 –273 2 Cambach W, Chadwick-Straver RV, Wagenaar RC, et al. The effects of a community-based pulmonary rehabilitation programme on exercise tolerance and quality of life: a randomized controlled trial. Eur Respir J 1997; 10:104 –113
Ousama Dabbagh, MD Carl Kaplan, MD, FCCP University of Missouri-Columbia Columbia, MO Correspondence to: Ousama Dabbagh, MD, Chief Fellow, Division of Pulmonary, Critical Care Medicine, University of MissouriColumbia, One Hospital Dr, MA417, Columbia, MO 65212; e-mail: [email protected]
References 1 Paterson I, Schwartzman K. Strategies incorporating spiral CT for the diagnosis of acute pulmonary embolism: a costeffectiveness analysis. Chest 2001; 119:1791–1800 2 Dabbagh O, Alsaleem AS, Alyaseen S, et al. The Spiral CT and D-dimer Correlation for the Diagnosis of Pulmonary Embolism Study [abstract]. Chest 2001; 120:S200
Salmeterol Powder Provides Significantly Better Benefit Than Montelukast in Asthmatic Patients Receiving Concomitant Inhaled Corticosteroid Therapy To the Editor:
Spiral CT Is Not the Final Answer To the Editor: We enjoyed reading the article by Paterson and Schwartzman in CHEST (June 2001),1 concluding that “spiral CT can replace ˙ pulmonary angiography in patients with nondiagnostic V˙/Q [ventilation/perfusion] scans.” We wish to raise several issues regarding these recommendations. This conclusion is based solely on a hypothetical model that does not represent actual clinical practice and decision making. We think that adopting their diagnostic approach may not be sufficient to exclude clinically significant pulmonary embolism. Furthermore, this could potentially lead to unnecessary treatment or lack of appropriate anticoagulation. First, there are known issues surrounding subsegmental pulmonary emboli. It is known that the sensitivity of spiral CT in this area is not high. Relying on spiral CT in these situations may result in missing small peripheral clots and their potential impact on patients with limited cardiopulmonary reserve. Second, the differences among radiologists in interpreting helical CT, especially in centers with less experience, are considerable. This fact was not discussed in this article or taken into account in their model. www.chestjournal.org
I have read with interest the study by Fish et al (August 2001).1 In this study, salmeterol added to inhaled corticosteroids was statistically superior to adding montelukast to inhaled corticosteroids in improving a number of traditional outcome variables such as morning and evening peak expiratory flow (PEF), percent of symptom-free days, percent of rescue-free days, supplemental albuterol use, nighttime awakenings, and some subjective symptoms. Reported daytime wheezing was not different. I am afraid that the design of this study favored this outcome as one of the inclusion criteria was an improvement in FEV1 of at least 12% to 2-agonists. Therefore, the observed results are not surprising, because an improvement of ⬎12% in FEV1 after treatment with 2-agonist was predetermined by these entry criteria. On the contrary, it is noteworthy that montelukast also improved the primary efficacy measure, which was PEF. While the authors claim that the sample size per treatment arm provided ⬎80% power to detect a significant difference of 15 L/min from baseline in the morning PEF, the mean difference between the two treatments observed was only 13.3 L/min. I question the scientific interpretation as well as the clinical significance of their observation. Furthermore, in my view, statistically significant differences such as a reduction of ⫺0.1 nighttime awakenings per week are hardly clinically relevant. Again, I question whether, indeed, salmeterol powder provides better benefit than monteCHEST / 121 / 6 / JUNE, 2002
2083